Extensive Epidermal Skin Loss Secondary to HSV Type One: Neonatal Management Challenges

Table 1

Table outlining the key management points when treating a neonate with widespread skin loss.

System-based considerations when managing a neonate with widespread skin loss
Respiratory	Invasive ventilation can allow the clinician to optimise analgesia administration and avoid further skin damage to the head and face.
Intravenous access	Intravenous access may be difficult to obtain and secure; maximise the duration of central line access with careful monitoring. Umbilical access should be secured to the umbilical cord and not the skin. UAC access facilitates blood sampling as heel prick blood sampling should be avoided.
Monitoring	Tailor how routine observations are performed and do not attach electrodes to the skin or use skin temperature probes. An oxygen saturation probe can be used to monitor the heart rate, and blood pressure measurements can be obtained via a UAC.
Fluids	There will be excessive fluid loss via the skin; therefore, fluid balance monitoring should be documented hourly to aid decisions on fluid management.
Nutrition	Nutrition is important to promote skin healing and should be considered early. If central venous access has been obtained, parenteral nutrition can be prescribed until milk feeds are commenced.
Analgesia	Hourly monitoring of pain using a classified pain scoring system will direct pain management. Rapid escalation of analgesia with drugs not typically prescribed in neonates may be needed; therefore, expert pharmacy advice should be accessed where available.
Jaundice	In this case, phototherapy was implemented effectively to treat jaundice with no obvious exacerbation to the skin.
Neurology	The clinician should be aware of the neurological complications related to HSV infection. If a lumbar puncture cannot be performed, liaise with a virologist to discuss treatment options. Cranial ultrasound and MRI scans should be used to aid diagnosis of neurological morbidity.
Microbiology	Consider HSV infection in a neonate presenting with widespread skin loss and obtain samples for viral PCR. Administer intravenous aciclovir early. There is an increased risk of infection; therefore, have a low threshold for commencing antimicrobial treatment if there are signs of infection.
Place of care	Transfer to a tertiary neonatal unit is advisable where all members of the MDT are available to offer expert review and treatment input.
Communication	Provide clear communication with the family at all stages of admission about treatment decisions and outcome expectations.
Specific skin considerations when managing a neonate with widespread skin loss
Handling	Ensure careful handling to avoid skin friction; handling techniques can be taught by the EB team.
Dressings	Give adequate analgesia 15 to 30 minutes prior to dressing application. Apply dressings to areas of raw skin, in this case Mepilex Transfer was applied, held in place with Tubifast bandage. Cling film can be used if no other dressings are immediately available.
Emollients	Apply emollients such as Dermol 500 and 50 : 50 Paraffin lotion to the skin. Emollients such as 50 : 50 Paraffin lotion can be applied to the fingers prior to handling.

UAC: umbilical arterial catheter; PCR: polymerase chain reaction.